Business Insurance Information Request

Fill out as much as you can on the form below so that we can help you:

Required information

Company name

(Legal name of business)

Type of business

Phone number

(###)

###

####

Location

Brief description of business

Other helpful information

Fax

(###)

###

####

Mailing address

(if different from location)

Website URL

http://

Federal tax ID number

(TIN)

When firm was established

(or prior experience of officers/partners in same industry)

Value of office furniture and equipment

Value of computers and/or electronic equipment

Any tenants improvements

(Built-in fixtures)

Stories of building

Building material

Fire resistant?

Yes

Area of office/work space in sq. ft.

Annual sales/revenues

Does your lease require liability insurance

Yes

How much?

(If you answered "no" to the last question, leave this blank)

Name of landlord

First Name

Last Name

Address of landlord

Do you have any employees?

Yes

How many?

(If you answered "no" to the last question, leave this blank)

Total annual payroll

Salespersons payroll

Clerical payroll

Number of male employees

Number of female employees

* This form is not an offer to buy insurance and will not result in coverage unless advised by agent.